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Original Research

Positive Affect and Survival in Patients With Stable Coronary Heart Disease: Findings From the Heart and Soul Study

Petra W. Hoen, PhD; Johan Denollet, PhD; Peter de Jonge, PhD; and Mary A. Whooley, MD

Published: July 15, 2013

Article Abstract

Objective: Positive affect can improve survival, but the mechanisms responsible for this association are unknown. We sought to evaluate the association between positive affect and mortality in patients with stable coronary heart disease and to determine biological and behavioral factors that might explain this association.

Method: The Heart and Soul Study is a prospective cohort study of 1,018 outpatients with stable coronary heart disease. Participants were recruited between September 11, 2000, and December 20, 2002, and were followed up to June 2011. Baseline positive affect was assessed by using the 10-item positive affect subscale of the Positive and Negative Affect Schedule. Cox proportional hazards regression was used to estimate the risk of mortality (primary outcome measure) and cardiovascular events (heart failure, myocardial infarction, stroke, transient ischemic attack) associated with positive affect, adjusting for baseline cardiac disease severity and depression. We also evaluated the extent to which these associations were explained by potential biological and behavioral mediators.

Results: A total of 369 patients (36%) died during a mean ± SD follow-up period of 7.1 ± 2.5 years. Positive affect was not significantly associated with cardiovascular events (hazard ratio [HR]: 0.89; 95% CI, 0.79-1.00; P = .06). However, each standard deviation (8.8-point) increase in positive affect score was associated with a 16% decreased risk of all-cause mortality (HR: 0.84; 95% CI, 0.76-0.92; P = .001). After adjustment for cardiac disease severity and depressive symptoms, positive affect remained significantly associated with improved survival (HR: 0.87; 95% CI, 0.78-0.97; P = .01). The association was no longer significant after adjustment for behavioral factors, and particularly physical activity (HR: 0.92; 95% CI, 0.82-1.03; P = .16). Further adjustment for C-reactive protein and omega-3 fatty acids did not result in any meaningful changes (HR: 0.94; 95% CI, 0.84-1.06; P = .31).

Conclusions: In this sample of outpatients with coronary heart disease, positive affect was associated with improved survival. This association was largely explained by physical activity.

J Clin Psychiatry 2013;74(7):716-722

Submitted: July 16, 2012; accepted November 12, 2012 (doi:10.4088/JCP.12m08022).

Corresponding author: Johan Denollet, PhD, CoRPS, Department of Medical and Clinical Psychology, Tilburg University, PO Box 90153, 5000 LE Tilburg, the Netherlands (

Volume: 74

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